Perineal Tears, To Stitch Or Not To Stitch?

When it comes to discussing perineal tears, there seems to be so much misinformation, so let’s chat.

First of all, we must touch on the fact that there a several different degrees of tears.

An intact layout of the exterior genitalia, as a baby crowns.

First degree

Second degree

Third degree

Fourth degree

WHY do Tears Occur?

Sometimes tears are unavoidable, especially small tears. Some babies come out with such force and pressure, pulling the perineum tight in response, and can cause the skin to rip. In the moment, during a natural birth, will you feel it? Maybe, but you will probably be more focused on the fact that a child is emerging down your birth canal and about to come into the world to greet you, you won’t notice until afterwards, if you check, or if you go to pee and it burns on your perineum.

This study discusses how episiotomies, larger babies, an assisted vaginal delivery (with forceps or vacuum), an epidural, and induction, potentially being factors in tears.

This study reiterates how instrumental vaginal delivery can increase prevalence of tears, as well as length of transition (longer transitions were more so associated with tears, but we cannot help but wonder what caused those long transitions, but they don’t mention that).

Preventing Perineal Tears

  • STAY UPRIGHT, listen to your body and allow baby to descend naturally, without coached pushing or purple pushing, let FER take over
  • Gently apply a warm compress on your perineum as baby descends. If you can do this yourself entirely this is optimal. There’s no need to push on babies head, pull on your perineum, or enter your vagina like some providers do. As baby is naturally and successfully descending, simply place gentle pressure with a warm wash cloth (can add oil as well if desired) on the perineum
  • There is no indication the pre-labor stretching, massaging of the perineum, or kegels work to strengthen or loosen the perineum, so this is truly unnecessary. See a pelvic floor therapist if you are concerned about the firmness or lack thereof of your perineum during your pregnancy, a pelvic floor therapist may will have some good tips to protect those pelvic floor muscles!!

Can Perineal Tears be Managed Without Stitching?

There are many reasons why someone might want to avoid stitches. This includes the infamous “husband stitch,” prolonged healing, improper healing, lack of sterility, pain, swelling, pelvic floor impact, and more. Not to say that NOT getting stitches does not come with risks, because that choice does come with risks, too.

If you have a first degree or second degree tear, you may choose to heal naturally!

  • Comfrey root (found here), an herb that contains natural Allantoin (which also helps form the umbilical cord and the baby’s bladder in the womb), is an amazing all around healer and helps bind skin. Mixing this with warm, raw manuka honey (found here), turmeric (found here) and witch hazel (found here) can make a soothing, anti-bacterial, anti-fungal natural stitch to encourage your body to heal quickly on its own. Apply warm Nori wraps (found here) and/or gauze over the area to gently seal, and prevent mess and stickiness all over your underwear/postpartum pad.

Be sure to cleanse well with a peri bottle mix after every bathroom trip, and re-apply to prevent bacteria growth. This does not always work for every individual and even after making this choice, it’s very possible to decide to get stitches. Should you change your mind, you can always go to the local ER to request stitches. Or, you may decide to get stitches right away, that’s fine too!!

A common misconception is that a hospital transfer is required for stitches. Nope! If you have a midwife, she can stitch you, too!! And luckily, tear repair is not something that you have to absolutely rush to the ER for right away even if unassisted. You should give a hustle if you have a severe tear, but for a tiny tear, enjoy those golden hours with your babe and then go, and do not admit baby, then check out once you’ve been stitched. There’s no reason to be admitted for 48 hours for stitches, because they will dissolve in a few weeks anyways, but if you want to stay, you can do that too.

An example of perineal stitches:

How To: Choose A Back-Up Doula

I always joke that you should be as picky with your Back-Up Doula/Business Partner, as you are about your Life Partner/Spouse and to not be afraid to date, take a break, break-up entirely, or stay together forever… LOL but honestly, that’s pretty valid!

You want to seriously know their values, their experience, their comfort zone, their training and capabilities, availability, financial requirements, childcare situation, what supplies they bring to the table, and more!

Can you genuinely work together without conflict? Would you want this individual at YOUR birth? Would you feel comfortable at theirs?

Taylor’s sweet back-up doula, Hope, when they attended a birth together in 2019

When choosing a back-up doula to take on a client, or clients, of yours, you need to discuss and agree in several areas.

  • Fee that will be provided in the event that one of you back up the other (does it change whether the back up is there 2 hours or 24 hours?)
    Tip: I firmly believe that 30-50% of the birth fee is fair, especially if you provided a few prenatal appointments and intend to follow up postpartum, but also have to consider how the back-up doula has to be on-call and attend the birth, which genuinely is a lot of work. It is much easier if you collect the full payment from the client prior to birth, and pay the back-up doula yourself, so there is no confusion between the client, you and the back-up.
  • What circumstances you can call them in (any and all, preferably, because emergencies get weird)
  • What their availability timeframe will be (36 weeks to 42 weeks, or a slimmer timeframe? Weekends only? Weekdays only?)
  • How quickly can they get to a birth? Where is their home-base (where they live)?
  • What can they bring to a birth? What if they do not have the same tools in their bag that your client prefers?
  • What experience/training do they have? Is it pretty equivalent to yours? If not, how can you ensure they do?
    Tip: I prefer to attend a birth or two with my back-ups before relying on them AS a back-up, so I can see their style, if they are honest about their availability, their energy in a birth space, and more. If it takes them 2 hours to get there when they live 20 minutes away, they seem confused or intimidated in the birth space, this does not necessarily mean that they are completely written off, but it does mean we need to have a new discussion on realistic expectations, needs, and how we can address their energy and how to improve. You have to be able to have open communication.
  • Do they have a friendly face, demeanor, and energy in general? If you were interviewing for a doula for your birth, would you hire them? You definitely do not want your clients feeling disappointed in the services your back-up doula provided because then they will feel disappointed in YOU and your business, and will be less likely to recommend you, and hire you in the future.

A Back-Up Doula is a Must Have

ALWAYS discuss the possibility of a back-up with your clients, even if you see no way that it could happen. Your clients need to have their contact information, business information, and potentially even an option to meet them – just in case! If you got struck by lightning, got into a severe car accident, or had a serious family emergency, you would want the comfort of knowing your back-up doula had everything covered and your clients would not be left feeling alone.

Whomever you hire, remember you are not stuck with them forever if they are absolutely terrible and do not be afraid to break it off if the relationship stinks, because your clients are a priority! Interview and meet with several different people as potential back-up doulas.

Some doula businesses even run on a two-doula method, where two doulas attend prenatal appointments, births, and postpartum together, or they alternate attendance. There are also doula agencies that clients may receive one of several different doulas. If this is something you are interested in, you should definitely explore it for your business, they are cool models of business!

Three of our Doula students supporting each other!

Is your Midwife there to serve YOU? – Questions to ask a Potential Midwife

So you want to hire a homebirth midwife?

That’s a great choice! There are many great midwives that serve women all across the world. They usually serve in a more natural-minded manner, and know more about physiological birth than their obstetric counterparts.

When you go about hiring a midwife, it is important to be aware that they are not one size fits all. They are each very different, will practice differently, will have different views on what physiological birth is, and not all midwives are ideal for YOU.

When choosing a midwife, be aware that most are limited in how they can serve you, due to state laws. Most licensed midwives will not serve you completely autonomously without risking the loss of their license; which is sad – but important to be aware of, as many women are not. There are also midwives that are not bound by legalities and can serve you completely autonomously. These women are often considered Traditional or ‘underground’ midwives.
I’ve also heard of licensed midwives who are willing to bend rules and fudge numbers to ensure a safe, out of facility delivery – making you the number one priority.
Be sure you know who you have along for your journey before hiring!

Questions for Your Midwife

1. What does a physiological home birth look like to you?

Some may have a more medical version of home birth in mind with monitoring vitals, checking the cervix, and so on. Some will have a more natural flowing version where medical monitoring/assisting only occurs when needed.

2. How often do you need to monitor baby?

In some states, licensed Midwives are required to monitor baby every few minutes. This can be an unnecessary bother during labor. If this is something you’d like to avoid, be sure your midwife is able to support your choice of limited monitoring.

3. Are cervical checks ever required, if so, how many?

Most women do not enjoy cervical checks during labor. They can be hindering during labor and are 100% unnecessary. If your birth plan is to avoid cervical checks, be sure to discuss this, as some may require them.

4. What  could cause me to ‘risk-out’ of your care?

Closer to the end of pregnancy, many women are shocked when their provider tells them they’ve “risked out” of care. This means you are no longer a client and they will no longer serve you. Some midwives will risk you out for silly reasons, such as baby being breech, solely to protect their license. Be sure you are aware of every situation that could risk you out of their care before signing a contract.

5. What would necessitate a transfer during labor?

During labor, your midwife can choose to transfer you. Transfer is necessary in some situations! Unfortunately, some will choose to do so for unnecessary reasons and without warning. Of course, you can refuse transfer, but they may be required to call 911 before they leave – this then becomes your issue to deal with while you are vulnerable. Some will transfer for silly reasons such as two slightly elevated blood pressure readings, baby being breech, or “failure to progress”. Be sure you are aware of all scenarios your provider will transfer for, before labor. It is important to also discuss what you will do in the case of a suggested unnecessary transfer. Will you stay home and continue with delivery or will you do as she suggests? This should all be discussed prior to laboring day.

It’s comforting to believe that all home birth midwives have your best interest at heart, but this unfortunately is not always the case. Those are a few questions that might be able to help you decipher if she is more concerned about you or licensure.

A few things you could do to protect yourself if your midwife drops you or suggests unnecessary transfer would be:

  1. Do not pay in full until the deadline of payment.
  2. Be informed on your state’s midwifery laws and the legalities surrounding.
  3. Have a plan of what you will do in the case she drops you out of care.
  4. Discuss each unnecessary transfer scenario and what you and your partner would do if she made the suggestion to transfer.
  5. Discuss with your midwife prior to labor what you will do if she feels she needs to leave your birth to protect her license. Discuss each situation and scenario.
  6. Make sure there is a refund policy in your contract, be sure you agree with it.
  7. Be sure your partner and/or Doula are in the loop with all of the above because they will be the ones you look to for support if your midwife drops you or suggests transfer. Everyone involved should know what would cause you to “risk out” of care, as well as what might necessitate a transfer. No need for surprises on laboring day!

Final Thoughts

I’ve heard too many stories where a home birth midwife left a woman hanging, mostly for unnecessary reasons. Most times, the woman was unaware that their midwife could abandon them like they did. Most did not get any amount of refund, and many were left with traumatic births. This is what drove me to create this article. Women in their childbearing years need to be aware that this can happen. They need to know what questions to ask and how to decipher if the potential midwife is a good fit, prior to signing a contract and paying in full. She can be a sweetheart and say she supports, you but there is more to it than that.

Again, not all midwives are the same. It’s important to acknowledge that there are a few snakes in the grass. Many midwives will have your best interest at heart, will bend silly rules for you, and put you before themselves – be sure the woman you hire is one! There are amazing midwives out there, you just have to look! Keep in mind, if your midwife is driven by the law, that is exactly what she will deliver.